Remote LPN/LVN - Utilization Review & Appeals (UM)

Integra Partners; Austin (TX); A distancia; USD 60.000 - 80.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

401(k) retirement program with company

Company-paid life insurance

Company-paid short term disability

Medical, Vision, and Dental benefits

Paid company holidays and floating hol

Remote opportunities

Descripción de la vacante

Integra Partners is looking for an LPN/LVN experienced in the managed care payor environment to perform pre-service and post-service utilization reviews and appeals for DMEPOS. This role collaborates with our Medical Director to conduct benefit and medical necessity reviews within an NCQA-compliant UM program.

The UM Nurse will review criteria, approve eligible requests, and refer non-qualifying cases to the Medical Director while processing appeals and ensuring compliance with NCQA, CMS, and

Formación

• Active LPN/LVN license in good standing.
• Minimum 3 years nursing experience in acute or outpatient settings.
• Minimum 2 years UM experience in a managed care/payor environment.
• Experience with Medical Necessity Criteria (InterQual, CMS, policies).
• Experience writing denial letters preferred.

Responsabilidades

• Perform pre-service and post-service UM reviews using mandates, benefits, and criteria for medical necessity.
• Approve requests that meet eligibility and medical necessity criteria.
• Refer cases not meeting criteria to Medical Director.
• Process administrative and clinical appeals and refer as needed.
• Maintain compliance with NCQA, CMS, and State standards.

Conocimientos

UM experience

Nursing skills

Medical necessity review

Educación

LPN/LVN license

Herramientas

InterQual

CMS guidelines

health plan policies

Descripción del empleo

Integra Partners is looking for an LPN/LVN experienced in the managed care payor environment to perform pre-service and post-service utilization reviews and appeals for DMEPOS. This role collaborates with our Medical Director to conduct benefit and medical necessity reviews within an NCQA-compliant UM program.

The UM Nurse will review criteria, approve eligible requests, and refer non-qualifying cases to the Medical Director while processing appeals and ensuring compliance with NCQA, CMS, and